Cerebral venous sinus thrombosis: An unusual initial presentation of mucinous adenocarcinoma of stomach

Subhransu Sekhar Jena¹, Soumyadarshan Nayak¹, Ishwar Chandra Behera², Debahuti Mohapatra³, Subrat Kumar Tripathy⁴,  
¹ Department of Neurology, Institute of Medical Sciences and Sum Hospital, Siksha 'O' Anusandhan University, Bhubaneswar, Odisha, India
² Department of Critical Care, Institute of Medical Sciences and Sum Hospital, Siksha 'O' Anusandhan University, Bhubaneswar, Odisha, India
³ Department of Pathology, Institute of Medical Sciences and Sum Hospital, Siksha 'O' Anusandhan University, Bhubaneswar, Odisha, India
⁴ Department of Biochemistry, Institute of Medical Sciences and Sum Hospital, Siksha 'O' Anusandhan University, Bhubaneswar, Odisha, India

Correspondence Address:
Subhransu Sekhar Jena
Department of Neurology, Institute of Medical Sciences and Sum Hospital, Siksha «SQ»O«SQ» Anusandhan University, Bhubaneswar, Odisha
India

Full Text

Sir,

Thrombotic events in cancer patient manifest commonly as deep venous thrombosis or pulmonary embolism and in less common sites, like veins of cerebral circulation. [1] Thrombosis can represent the earliest clinical manifestation of an occult malignancy, as revealed by study demonstrating idiopathic venous thrombosis have a 4-7 fold increased risk of being diagnosed with cancer in the first year, as compared with secondary causes. [2] Here we describe a case of carcinoma stomach initially presented as cerebral venous thrombosis (CVT), hitherto unreported in the literature.

A 56-year-old lady presented with headache and intermittent projectile vomiting for 10 days. She developed right side focal motor seizures with secondary generalisation (six episodes in last 2 days) and altered sensorium for 2 days. She was not taking any hormonal preparation. There was no prior history of spontaneous abortion or history suggestive of collagen vascular disease. At admission, Glasgow coma scale (GCS) was 13/15 (E4V4M5). She had bilateral papilloedema. There was right sided hemiparesis. There was no pallor, jaundice or lymphadenopathy. On per abdominal examination a firm epigastium mass of 3 × 5 cm dimension was felt. There was no hepato-spleenomegaly.

Magnetic resonance imaging (MRI) brain showed acute venous hemorrhagic infarction and swelling over left tempero-parieto-occipital lobe with mild mass effect. The MR-venography demonstrated left sided sigmoid and left transverse sinus thrombosis. Post contrast study shows patchy enhancement of the abnormal area [Figure 1]. Laboratory findings revealed haemoglobin 13.1 gm%. Liver and renal function test were within normal range. Anti nuclear antibody (ANA), Anti double stranded DNA (DsDNA), Complements, anti cardiolipin antibody were normal. Prothrombin time (PT), Activated partial thromboplastin time (APTT), Platelet count were normal. Sickling test was negative. A full thrombotic workup showed normal prothrombin, activated partial thromboplastin and thrombin time. Factor VIII, fibrinogen, antithrombin III level and activated protein C resistance ratio were normal. The lupus anticoagulant was negative. The protein C and protein S functional assay were within the normal range. Genetic markers for thrombosis like factor V Leiden mutation, methylene tetra hydro folate reductase and prothrombin gene polymorphism were not detected.{Figure 1}

For the evaluation of epigastric mass, ultrasound abdomen was done, which showed asymmetrical mural thickening of antropyloric region. Computer tomography (CT) abdomen demonstrated segmental enhancing wall thickening involving antropyloric region of stomach and few subcentimeter perigastric nodes. Upper gastrointestinal (GI) endoscopy showed a ulcero-nodular growth involving incisura [Figure 2]. The biopsy of the lesion suggested gastric mucosa along with tumor tissue. The tumor cells are seen arranged in acini, cord and sheets showing moderate nuclear pleomorphisim, increased N: C ratio, hyperchromatism, increased mitosis along with few signet ring cells. The tumor is infiltrating the muscularis mucosa [Figure 3]. So diagnosis of mucinous infiltrating adenocarcinoma of stomach was made.{Figure 2}{Figure 3}

She was treated with low molecular weight heparin, antiepileptics and anti edema measures. After 1 month of neurological stabilisation; she underwent subtotal gastrectomy with lymphnode resection. The omental nodes did not reveal any metastatic deposists. Post operation she did not have any complications. At 3 months of follow-up she improved to a modified Rankin scale of 2.

In one series, cancer accounted for 7.4% of all CVT and 2.2% were associated with central nervous system (CNS) malignancy, 3.2% with solid tumors outside the CNS and 2.9% with hematological disorders. [3] A study in Chinese population, revealed, of the 376 deep venous thrombosis (DVT) cases, 4 cases were associated with carcinoma stomach. [4] CVT in association with malignancy was observed in 4 (0.9%) cases like acute lymphoid leukemia and carcinoma tongue in a study from India. [5] Usually the venous thrombosis is seen during the course of malignancy. DVT sometimes may antedated the diagnosis of bronchogenic carcinoma. [4] But the CVT antedating carcinoma stomach has not been reported in the literature. The association of cancer with CVT may be due to various possible mechanisims like, direct tumor compression, tumor invasion of cerebral sinuses, hypercoagulable state, chemotherapeutic side effects or paraneoplastic effects. [6] In our case probable etiology may be hypercoagulable state or paraneoplastic effects of mucinous adenocarcinoma.

Mucin-producing adenocarcinomas are particularly notorious for venous thrmbosis. The cell surface compositions like saccharide and mucin content is altered producing more adhesiveness and coagulation abnormalities. [7] Mucin circulates and stimulates platelet aggregation in response to L-selectin in thrombocytes and P-selectin in leukocytes. [7] Heparin inhibits platelet aggregation by inhibiting the ligand of selectin and binding of mucin and selectin. [7]

Clinicians should be aware of the potential of carcinoma stomach for causation of CVT. The early diagnosis of carcinoma stomach has definite prognostic role as, appropriate medical and timely surgical interventions are crucial. The CVT can be the first manifestation of an occult malignancy, and patients presenting with idiopathic CVT are more likely to have underlying cancer than those in whom a secondary cause of thrombosis is apparent.

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